Labral Repair

The goal of labral repairs is to restore a stable acetabular labrum that sits against the femoral head and recreates the hip suction seal. When the labral tissue is viable, preservation and repair are preferred to excision because the labrum contributes to joint stability, fluid pressurization, and load distribution. Labral excision and reconstruction can be considered for patients whose labral tears are non-repairable.

Suture techniques:

Two common suture configurations are used. The technique can be changed along the same tear depending on labral size, tissue quality, and the shape needed to restore contact with the femoral head.

Technique	How it works	Considerations
Loop repair	The suture loops around the entire labrum	Simple and useful for thinner tissue. Can cause eversion and loss of seal.
Mattress repair	The suture is passed through the base of the labrum to secure it directly back to the acetabular rim without looping the labrum.	Can better recreate the native triangular labral shape. Requires adequate tissue. Risk of cut-through.

Anchor styles:

Knotted and knotless anchors are both commonly used. Knotted anchors provide greater control over specific loop configuration. Knotless systems avoid a knot stack within the joint. Current evidence supports both approaches, and neither has made the other obsolete.

General steps:

1. Assess the tear and tissue quality

Before placing an anchor, define the full extent of the tear with a probe. Note the clock-face location, and whether the labrum is detached from the rim or split within its substance.

2. Prepare the acetabular rim for fixation

The acetabular rim immediately adjacent to the detached labrum is exposed so that anchors can be placed into bone and the labrum can heal back to the rim. Take care to preserve viable labral tissue and the chondrolabral junction whenever possible.

3. Place the first suture anchor

Anchor placement usually begins at one end of the tear and progresses sequentially across it. Beginning at the more posterior or superior end of the tear prevents the repaired segment from blocking visualization or access to the remaining tear.

4. Pass the suture through or around the labrum

The suture configuration (loop versus mattress) is selected according to the tissue quality. A small suture passer is used to minimize trauma to the labrum.

For a loop repair, the suture is passed around the free edge of the labrum to create a loop. This is useful when the labrum is relatively thin or when passing multiple limbs through the tissue could cause damage.

For labral mattress fixation, the suture passer penetrates the base of the labrum, and the construct secures the base back to the acetabular rim. This technique is intended to preserve the free edge while recreating the native anatomy of the labrum.

5. Tension and secure the repair

The suture is tensioned until the labrum is reduced to the rim and sits naturally against the femoral head. With a knotted construct, the knot is advanced and kept on the acetabular side of the repair. With a knotless anchor, tension is adjusted before final locking. Over-tensioning can flatten the labrum against the acetabulum or pull it away from the femoral head.

6. Complete the repair and test the suction seal

Additional anchors are placed sequentially across the tear. They should be spaced evenly to provide continuous fixation without overcrowding the rim.

Once the repair is complete, probe the labrum to confirm that the segment is fixed in a satisfactory position. Inspect the acetabular cartilage for evidence of anchor or drill penetration and ensure that sutures or knots are not prominent against the femoral head.

Traction can then be reduced or released to assess contact between the labrum and the femoral head. A successful repair should recreate a circumferential seal as the femoral head returns into the acetabulum.

Common technical problems

1. Poor anchor angle

Drilling too close to the articular surface can penetrate acetabular cartilage. To avoid this visualize cartilage while drilling and use fluoroscopy as needed.

2. Labral eversion

Poor anchor placement to far from the rim or excessive suture tension can cause the labrum to evert and prevent adequate seal formation.

3. Suture cut-through

Repeated passes, large penetrators, or aggressive tension can tear thin or degenerative tissue. Using loop sutures instead of mattress sutures in frayed tissue can reduce suture cut-through.

4. Knot prominence

With knotted repair, keep the knots on the acetabular side of the labrum facing away from the femoral head to avoid interference with ROM.

5. Incomplete repair

Define the entire tear before fixation and ensure the anchors span from stable tissue to stable tissue after fixation to prevent incomplete repairs.

References